Mt. San Rafael Hospital Survey Dear Trinidad Community Member,We appreciate the time you're taking to complete this survey. Your answers are confidential, and will be used to create priorities to improve your community's health. You must be at least 18 years old to complete the survey. Please answer thoughtfully and honestly.Any questions can be directed to mb@coruralhealth.org.Sincerely,Mt. San Rafael Hospital Question Title * 1. If you or someone in your household received hospital services within the last two years, what hospital did you visit? Mt. San Rafael Hospital Parkview Medical Center St. Mary Corwin Medical Center Miner’s Colfax Medical Center Other (please specify) Question Title * 2. If you responded that you or someone in your household received care at a hospital other than Mt. San Rafael Hospital, why did you or your family member choose that/those hospital(s)? Physician referral Quality of care/lack of confidence locally Closer, more convenient Availability of specialty care Insurance Other (please specify) Question Title * 3. If you were an inpatient at Mt. San Rafael Hospital, how satisfied were you with the services? Satisfied Dissatisfied Why? (please specify) Question Title * 4. Within the last two years, what services have you used at Mt. San Rafael Hospital? Radiological imaging (X-ray, MRI, CT, Ultrasound, Mammogram, Dexa Scan) Laboratory Physical, Occupational or Speech Therapy Emergency room (ER) Colonoscopy/Endoscopy General Surgery Gynecology Other (please specify) Question Title * 5. What specialists have you or someone in your household used in the past two years? Allergy ENT Dialysis Cardiology/Heart Dermatology Asthma Obstetrics-Gynecology Oncology Obesity Orthopedic Surgery Pain Management Diabetes Neurosurgery Urology Podiatry Vascular Surgery Audiology Other (please specify) Question Title * 6. Please list the clinic and city where you saw each specialist: Question Title * 7. Did the specialist request further testing, laboratory work and/or x-rays? Yes No If yes, in what facility were the tests or laboratory work performed? Question Title * 8. If you were an outpatient at Mt. San Rafael Hospital within the past 2 years, how satisfied were you with your services? Satisfied Dissatisfied Why? (please specify) Question Title * 9. Do you have a primary care provider? Yes No Question Title * 10. Do you use a medical clinic for most of your routine outpatient healthcare? Yes No Question Title * 11. Where do you receive your local healthcare? (List all that apply.) Mt. San Rafael Hospital Clinic Mt. Carmel Clinic Other (please specify) Question Title * 12. Are you able to get an appointment within 48 hours with your medical provider? Yes No Question Title * 13. Do you feel additional services need to be provided earlier in the morning or after hours, including Saturdays and walk-in appointments? Yes No Question Title * 14. Does a sliding fee scale (discount from full fee) allow you or someone in your household to access health services? Yes No Question Title * 15. Have you or someone in your household delayed healthcare due to lack of money and/or insurance? Yes No Question Title * 16. Do you think there are enough medical providers practicing in the county? Yes No Question Title * 17. Where do you receive your medical services? If not in Las Animas County – Why? Question Title * 18. Do you believe Mt. San Rafael Hospital has services that support residents in managing their own health – in other words, helping residents to be more aware of available healthcare resources, home health services, and of disease prevention? Yes No Question Title * 19. What additional services, if any, would you like to see Mt. San Rafael Hospital or Clinic offer residents to help them manage their own health? Question Title * 20. To what extent are you concerned about access to care – ability to get an appointment at a time that works for you? 1 = not very concerned 2 3 4 5 = very concerned Question Title * 21. To what extent are you concerned about the costs and out of pocket expenses of healthcare? 1 = not very concerned 2 3 4 5 = very concerned Question Title * 22. To what extent is it difficult for you or someone in your household to comply with follow up care instructions – further evaluation, therapy, and medications? 1 = not very difficult 2 3 4 5 = very difficult Why? (please specify) Question Title * 23. Are you concerned about transportation to get to medical services you may need? 1 = not very concerned 2 3 4 5 = very concerned Question Title * 24. What do you believe to be the most important health or medical issues confronting the residents of your area? For Example - No health insurance, chronic disease, etc. (Please explain) Question Title * 25. In the last two years, have you or anyone in your household left the area in search of medical care? Yes No Why? (please specify) Question Title * 26. During the past year, what health care services did you need and were NOT able to get, and what was the reason? Appointment Not available Dr. or service would not accept insurance Dr. or service would not accept Medicaid Could not afford to pay co-pay Don't know Services Not needed or I (we) were not able to go A doctor visit, checkup or exam A doctor visit, checkup or exam Appointment Not available A doctor visit, checkup or exam Dr. or service would not accept insurance A doctor visit, checkup or exam Dr. or service would not accept Medicaid A doctor visit, checkup or exam Could not afford to pay co-pay A doctor visit, checkup or exam Don't know A doctor visit, checkup or exam Services Not needed or I (we) were not able to go Mental health care Mental health care Appointment Not available Mental health care Dr. or service would not accept insurance Mental health care Dr. or service would not accept Medicaid Mental health care Could not afford to pay co-pay Mental health care Don't know Mental health care Services Not needed or I (we) were not able to go Medical supplies or equipment Medical supplies or equipment Appointment Not available Medical supplies or equipment Dr. or service would not accept insurance Medical supplies or equipment Dr. or service would not accept Medicaid Medical supplies or equipment Could not afford to pay co-pay Medical supplies or equipment Don't know Medical supplies or equipment Services Not needed or I (we) were not able to go Appointment or referral to a specialist Appointment or referral to a specialist Appointment Not available Appointment or referral to a specialist Dr. or service would not accept insurance Appointment or referral to a specialist Dr. or service would not accept Medicaid Appointment or referral to a specialist Could not afford to pay co-pay Appointment or referral to a specialist Don't know Appointment or referral to a specialist Services Not needed or I (we) were not able to go Other medical treatment (tests, surgery, x-ray, cancer or heart attack tests) Other medical treatment (tests, surgery, x-ray, cancer or heart attack tests) Appointment Not available Other medical treatment (tests, surgery, x-ray, cancer or heart attack tests) Dr. or service would not accept insurance Other medical treatment (tests, surgery, x-ray, cancer or heart attack tests) Dr. or service would not accept Medicaid Other medical treatment (tests, surgery, x-ray, cancer or heart attack tests) Could not afford to pay co-pay Other medical treatment (tests, surgery, x-ray, cancer or heart attack tests) Don't know Other medical treatment (tests, surgery, x-ray, cancer or heart attack tests) Services Not needed or I (we) were not able to go Medications/Prescriptions Medications/Prescriptions Appointment Not available Medications/Prescriptions Dr. or service would not accept insurance Medications/Prescriptions Dr. or service would not accept Medicaid Medications/Prescriptions Could not afford to pay co-pay Medications/Prescriptions Don't know Medications/Prescriptions Services Not needed or I (we) were not able to go Immunizations Immunizations Appointment Not available Immunizations Dr. or service would not accept insurance Immunizations Dr. or service would not accept Medicaid Immunizations Could not afford to pay co-pay Immunizations Don't know Immunizations Services Not needed or I (we) were not able to go Question Title * 27. What is your zip code? 81082 81020 81046 81027 81049 81091 81024 Other (please specify) Question Title * 28. What is your age range? 18-25 26-39 40-54 55-64 65 or over Question Title * 29. What is your annual household income range? Under $25,000 $25,000-$49,000 $50,000-$75,000 Over $75,000 Question Title * 30. What type of health insurance do you have currently? (Check all that apply) Uninsured Private Pay Insurance Employer Sponsored Insurance Public (Medicaid/Medicare/CHP+) Vision Insurance Dental Insurance Thank you for your participation! Done